The job of medicine can make us assume mindsets that are mostly unhelpful to us and our patients.
I had the rare pleasure of catching up with an old school friend recently in a local café by the beach.
Trendy people ordered trendy drinks with trendy dogs lazing at their feet. The sun was partially obscured by low clouds, while the light sea breeze cut through the rising humidity that infests the early summer months on the NSW far north coast. Sitting bare foot in the sandy grass, I practised social and green self-prescribing. It was refreshing.
As we talked about where our lives have gone over the last quarter of a century since high school ended, it was fascinating to see some common threads between our different professions. He had been on the road to being NSW police commissioner – a road he won’t travel any longer due to PTSD. Despite his progression through the ranks and being identified by his peers for this very lofty future calling, the nature of the job and, crucially, his doubts about his own ability have forced a career change.
While there is conversation regarding PTSD and burnout among doctors, there’s less discussion of the masks we wear in order to keep ploughing on. And no, I’m not thinking N95s, but those invisible professional shrouds that allow us to fulfil our role and the expectations – of patients, institutions, communities and governments as well as ourselves – that accompany it.
The disbelief in your own competence despite objective successes and external validation is known as impostor syndrome. Sufferers attribute such successes to coincidence, to having a friendly disposition or to luck, and live in fear of being exposed as a fraud. If you’ve ever had the thought why don’t my patients see a real doctor instead of me?, it’s likely you’ve experienced impostorism.
Dr Bethany Boulton, an ED physician, wrote a great summary for The Medical Republic in her 2021 article “To my friend, the impostor”. The syndrome is akin to that intrinsic sense of believing (or not) that you’re beautiful/handsome, intelligent or talented. In a word: worthy. It’s a syndrome that’s observed in high achievers across multiple professions and affects women more commonly than men. Experienced by up to 70% of us during our lives, it’s thought to be due to an unrealistic and unsustainable expectation of competency. This is often a new challenge for many of us who, at least academically (i.e. our childhood professions), are used to feeling secure.
While all good doctors have the Hippocratic first, do no harm mantra tattooed on their frontal lobes, this can actually be a negative way to practise. Of course, we should avoid all preventable harm to our patients and communities, but the “no harm” standard also sets us up to fail. Inevitably during our careers, we’re going to miss things that, on retrospective analysis, we could or should have identified or managed differently. The guilt (or fear of the guilt) that attends these situations hollows out self-belief and drives impostor syndrome. It contributes to burnout and disengagement as a doctor and if left unchecked may even lead to anxiety or depression.
The flipside of impostor syndrome, however, is its positive role in self-appraisal and patient safety-netting. If we’re diligent (not obsessive) in appearing competent – even if we don’t believe it ourselves – and this supports our delivery of best-practice care to our patients, then they reap the benefits of impostor syndrome. Those nights we lie awake thinking about that extra test that could have been done (that any competent doctor would have done) or that extra line in a referral that could have been included (as a competent doctor would have) underpin performance review and quality improvement.
Remember that. Omissions can be corrected or things done differently next time around. Learning from our internal review processes is the key, rather than being drowned by a guilt burden.
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The other mask we adopt from time to time is that of the white knight. I don’t mean the save-the-planet superhero variety, but those with saviour syndrome. This occurs when we feel the need to rescue or save our patients from their problems. It creates a paradox when the essence of being a doctor is to problem-solve and advocate.
If we only feel good about ourselves when saving others (watch out for the self-serving secondary gain that’s occurring here!), believe helping others is our purpose for being, believe that we’re the only one who can solve the problem or expend excessive energy to rescue our patients from their problem (I say again, their problem), then we’re probably in saviour syndrome territory.
It occurs in professional as well as personal relationships. Aside from the physical and mental impacts of trying to save our patients (i.e. burnout, a sense of failure when everyone can’t be saved or opportunity costs from being overinvested), it may also disempower the patient. This is especially important to avoid when practising in a trauma-informed manner. Though patients generally come seeking help from their doctor, they may not want us to solve the whole puzzle, but rather to sit and help them work out how the pieces fit together.
While balancing their agenda and ours is often a challenge, it’s part of the art of medicine and serves to strengthen the doctor-patient relationship in a modern, patient-centred model of care. Of course, there’s a power imbalance in the relationship, genuine care requirements that only the doctor can bring to this relationship and a duty of care to fulfil, but working together to solve the problem benefits both parties.
The other thing to be aware of is that we can experience both syndromes in different patients or in different consultations with the same patient. We can and do change our mask!
So how do we get the balance right? That’s a trickier proposition. The first step is to acknowledge and normalise these syndromes. Genuinely celebrate our victories. Give ourselves permission to make mistakes because they’re part of the learning process – both as a doctor and a human (after all, perfection is impossible due to a chronic lack of a crystal ball and magic wand).
Think, if a colleague came to me with this mistake, how would I respond? The answer is usually kinder than what we tell ourselves.
Listen to patients and support them to manage their own problems through appropriate provision of care – don’t try to save them. Remember we’re mentors, not rescuers. We should talk more about our inner impostor or saviour with colleagues (or psychologist, if needed). Finally, shift the narrative from syndromes that restrain to ones that, when harnessed for good, support quality improvement and help to make us better doctors in the long run.
Dr Elizabeth Hicks is a GP and author from the northern rivers region of NSW.
